Double-Burden of malnutrition

• Terminology
• Epidemiology
• Risk factors
• Prevention policy
• PA Quiz answers on intrapol

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What did you learn from
reading?

What do you understand by the term

Malnutrition?
 A world with a double burden of
“mal”nutrition…

1 billion “hungry”
•Even more suffer from “hidden hunger”
•150 million children underweight, 171m stunted
•The poor are more likely to be undernourished

1 billion
overwt. or
obese

•Cardiovascular
disease 1st cause
of death
worldwide
•DM affects 246m
people
•The poor likely
to develop and
die from NCDs
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Thin - acute Short- chronic
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Growth charts to monitor individudal children

Evaluate growth of individual over time

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 Proposed classification of global prevalence ranges of
low ht-for-age; low wt-for-age; & low wt-for-ht in children <5 yr

Prevalence ranges (% children below -2 Z scores)

low ht-for-age low wt-for-age low wt-for-ht

(stunting) (wasting) (wasting)
Low < 20% < 10% < 5%
(acceptable)
Medium 20-29% 10-19% 5-9%
(poor)
High 30-39% 20-29% 10-14%
(serious)
Very high > 40% > 30% > 15%
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(critical)
 Cutoffs used to identify nutrition problems of
public health significance

Category Stuntinga Underwt Wasting Overwtb IDAC VADC IDDC

Severe >40 > 30 >15 >10 >40 >20 > 30

Moderate 30-39 20-29 10-14 5-9 20-39 10-20 20-29
Mild 20-29 10-19 5-9 3-4 5-19 2-9 5-19
a WHO 1995, 2000
b By definition only 2.3% children should have wt/ht Zscore >2
Countries with >1,2,or 3 times higher than this normal prevalence are respectively categorised as having mild,
moderate or severe levels of overwt.
C WHO 2000

SOURCE: Annex 5.5 p. 210

Repositioning Nutrition as Central to Development: A Strategy for Large Scale Action; book;
268 pages; November, 2005 World Bank ISBN: 978-0-8213-6399-7;
http://books.google.dk/books?id=PRPc32wCLjMC&pg=PA210&lpg=PA210&dq=Category+of+Public+Healt
h+significance+overweight+IDD+VAD&source=bl&ots=Va7jzuJsoE&sig=a_f_l0kRfDNRBfzAx9UNBajNT-
g&hl=da&sa=X&ei=4JC4Uc6iHerJ0QXho4HoCQ&ved=0CEQQ6AEwAw#v=onepage&q=Category%20of%2 8
0Public%20Health%20significance%20overweight%20IDD%20VAD&f=false
Developmental origins of health & disease –
”Barker hypothesis” – Foetal programming

Foetal origins hypothesis suggest

alterations in foetal nutrition &
endocrine status that predispose an
individual to CDs in later life –
”thrifty genotype”

Source: Food & health in Europe p.47-8 & WHO publication

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171 million children under 5 are stunted

Source: WHO Global Database on Child Growth and Malnutrition, 2009

What risks are associated with
being stunted?

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Short- & Long-Term Effects of Early Nutrition

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“Window of Opportunity” for Improving Nutrition is
very small…pre-pregnancy until 18-24 months

0.50
0.25
Latin America and Caribbean
Weight for age Z-score (NCHS)

0.00
Africa
-0.25 Asia
-0.50
-0.75
-1.00
-1.25

-1.50
-1.75
-2.00
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (m onths)
Stunted children are more likely
to become overweight
RR 95% CI

Brazil 1.7 (1.2, 2.3)

S Africa 2.6 (2.0, 3.5)

China 4.2 (3.1, 5.7)

Russia 7.8 (5.7, 10.7)

Popkin et al., J Nutr

1996
 Nearly 1/3 of “high stunting-burden” countries
% have overweight+obesity rates >40%
80

70

60

50

40

30

20

10

Overweight + Obesity (all age 15-100 yrs) Stunting (age <5 yrs)

Data source: WHO Global Infobase Global Obesity Comparison Tool

May be difference in rates of underwt & overwt between urban
and rural women in developing countries

Mendez et al. AJCN 2005

Why do we want to reduce
double-burden of
malnutrition?

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 Reducing Malnutrition is essential to poverty
reduction

Malnutrition Poverty

• GDP losses  2-3%

• Leads to a >10% potential reduction in lifetime earnings for each
malnourished individual
• Undernutrition (stunting) in early years linked to a
– 4.6 cm loss of height in adolescence
– 0.7 grades loss of schooling
– 7 month delay in starting school

• Undernutrition linked to deaths of >3.5 million children/year (35%

of all child deaths in developing countries)

(Improved nutrition is a driver of economic growth)

Repositioning Nutrition, 2006
 Reducing Double-burden of Malnutrition is
essential to poverty reduction

Income growth will improve nutrition & improved nutrition

will increase income growth
World Bank 2006
Nutritional status according to level of wealth in Asian & Africa

Prevalence of Underweight by Wealth Quintiles

(Children <5 yrs, below -2SD)
Region Country Lowest 2nd 3rd 4th Highest
South Asia
Bangladesh 59 53 45 43 30
India 61 54 49 39 26
Pakistan 54 47 43 37 26
Africa
Benin 29 30 23 20 10
Burkina Faso 42 40 41 39 22
Ethiopia 49 51 51 45 37
Mozambique 31 28 26 19 9
Rwanda 27 30 28 24 14
Tanzania 25 26 22 20 12
Uganda 27 26 25 19 12

Source: Gwatkin et al, Country Reports on HNP and Poverty: Socio-Economic Differences in Health, Nutrition, and Population, April 2007
 Disabled by obesity. Some
young women affected suffer
from conditions such as early
diabetes, heart disease,
gallstones and arthritis, which
may immobilise and eventually
kill them. The obsession of
some Mauritanians with female
obesity is continuing to cripple
a small but extremely
vulnerable sector of its society.
In Mauritania, when it comes to
women, for many people fat is
beautiful. Here in this desert country,
where poverty and malnutrition affect
many, obesity is seen as a badge of
wealth and prestige.
 Maternal Overweight Rates
80 80
A FR A FR
Egypt EA P Egypt EA P
ECA
% maternal overweight (BMI>=25)

% maternal overweight (BMI>=25)

ECA
Jo rdan LA C Jo rdan
LA C
60 M NA 60 M NA
Turkey SA R
Turkey SA R
P eru
P eru
Guatemala Guatemala
M auritania M auritania
40 40

A rmenia
Haiti Haiti
Ghana Nigeria Zimbabwe Ghana
Zimbabwe Nigeria
20 Uzbekistan 20
Yemen Uzbekistan Yemen

Cambo dia India

Cambo dia India
B angladesh
0 B angladesh 0
0 10 20 30 40 50 0 15 30 45 60
% m aternal undernutrition (BMI<18.5) % child (<3y) underw eight (WAZ<2)

Under-nutrition often co-exists with over-weight… (both

are forms of malnutrition or malnourished obese)
Child underweight and maternal overweight in
the same household

Doak et al., Int J Obes 2005

 Diabetes type 2
• By 2030 - from 171 million (2.8% global
population) in 2000 to 366 million (6.8%)

• By 2030, 80% of all diabetics will live in

developing, 135% increase from 2000
(compared with 54% increase in developed
countries)

• Childhood-onset diabetes is increasing at 3%

per year, with some as young as 8yrs being
affected

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 ”Double burden” of disease
India

• 2nd most populous country, has highest

no. of diabetics in the world
• 1.6 million annual coronary deaths.
• 2.5 million children/yr estimated to die
from infections (pneumonia, malaria,
acute respiratory infections, diarrhoea &
neonatal infections)

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 example
Even in one family:
father with high blood pressure
mother who is anaemic & obese
children who are undernourished &
suffer frequent infections.

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 Conclusion
• Priority action continues to be maternal, infant, and
young child undernutrition

• Poverty predisposes to both undernutrition and

chronic disease

• Early intervention is critical - permanent damage is

done before 2 year
• Rapid weight gain after 2 years may predispose to
obesity and NCDs (short-fat kids)
• The earlier we act, the better (to prevent both
undernutrition, and risk of obesity and future NCDs)
 Next lesson on 25 October 12.15-14.00

HEALTH NUTRITION and INEQUALITIES

Obesity and Health Inequities in European Region

http://www.euro.who.int/__data/assets/pdf_file/000
3/247638/obesity-090514.pdf

SOLID FACTS
http://www.euro.who.int/en/publications/abstracts/s
ocial-determinants-of-health.-the-solid-facts

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